Medical Review Specialist V

Overview

Employer Industry: Government Services and AI Solutions

Why consider this job opportunity:

• Opportunity for part-time work with flexible scheduling
• Engaging role in analyzing Medicare claims and ensuring compliance
• Contribute to the integrity of government healthcare programs
• Supportive environment with a focus on employee development
• Chance to utilize clinical knowledge and make a meaningful impact
• Recognized as a 2024 Military Friendly Employer, committed to supporting veterans

• Review and analyze Medicare claims to determine payment eligibility based on coding and medical necessity
• Conduct in-depth analysis of claims for potential fraudulent billing practices
• Complete summary reports detailing claim determinations and clinical observations
• Meet established production standards for the number of claims reviews
• Communicate with team members and participate in quality assurance monitoring

• Registered Nurse (RN) with a Bachelor’s, Associate’s degree, or diploma
• Current licensure as a Registered Nurse in one or more states or D.C.
• At least 10 years of clinical experience
• Minimum of 7 years of claims knowledge from billing, reviewing, or processing
• Medical review experience required; ability to maintain confidentiality of sensitive information

• Previous experience in fraud review or investigation
• Strong proficiency in Microsoft Excel, Word, and Adobe PDFs
• Excellent organizational and time management skills

#Government Services #Healthcare Compliance #AI #Medicare #Veteran Support

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